Presentation on theme: "Taking an Environmental History to Address Children’s Unique Vulnerabilities to Environmental Health Risks Joel Forman, MD Associate Professor of Pediatrics."— Presentation transcript:
1 Taking an Environmental History to Address Children’s Unique Vulnerabilities to Environmental Health RisksJoel Forman, MDAssociate Professor of Pediatrics and Community and Preventive MedicineMount Sinai School of MedicineChildren’s Environmental Health Faculty Champions Initiative
2 Learning ObjectivesAt the end of this session the learner will be able to:Define ‘Pediatric Environmental Health’Describe 5 ways in which children are uniquely vulnerable environmental exposuresObtain an efficient Screening Pediatric Environmental Health History (Taking in to account children's unique vulnerabilities)Access additional tools to gather a more detailed environmental history when indicated.At the end of this session the learner will be able to:
3 Outline Definition: What is pediatric environmental health? Historical Perspective: The changing pattern of disease in childhoodThe Theory: Why children are not just little adults when it comes to environmental exposuresEvidence that supports this theory of unique vulnerabilityIncorporating a screening pediatric environmental health history into routine well child care and ill child care
5 Environmental health is the field of science that studies how the environment influences human health and diseaseNIEHS DefinitionThis definition comes from the National Institute of Environmental Health Sciences
6 “Environmental health includes both the direct pathological effects of chemicals, radiation and some biological agents, and the effects (often indirect) on health and wellbeing of the broad physical, psychological, social and aesthetic environment which includes housing, urban development, land use and transport.”World Health Organization DefinitionHere is a definition from the World Health Organization.
7 What Comprises the ‘Environment’ The natural environmentIncludes physical, chemical and biological things that occur naturally in our surroundings (air, water, food, soil)The man-made or “built” environmentIncludes physical structures where people live, work and play and the consequences of human alteration to the natural environment (e.g. pollution)The social environmentEncompasses lifestyle factors such as diet and exercise, SES and other societal influences that may affect healthNIEHSSo when we think about what is in the environment – because people mean different things when they talk about “environment” – here are the factors to include. This information is taken from the National Institute of Environmental Health Sciences - it is a very broad definition.Of course there is overlap between these categories. For example, the “built” environment often influences the social environment. An example of this is seen with the epidemic of obesity – lack of places to walk and play, lack of access to fresh unprocessed food, influence the development of what we eat and move around.
8 An Operational Definition of Pediatric Environmental Health The Diagnosis, Treatment, and Prevention of Illness due to Pediatric Exposure to Environmental HazardsThe Creation of Healthy Environments for Children
9 Historical Perspective The changing pattern of disease in childhood
10 Patterns of Disease in Children Have Changed Greatly in the Past 100 Years
11 The New Pediatric Morbidity A range of chronic disabling and sometimes life threatening conditions of complex and poorly defined origins that affect increasing numbers of American children todayAsthmaDevelopmental DisordersObesityEndocrine and Sexual Development DisordersCancerBob Haggerty 1975Asthma - PM, Solvents, ETSDevelopmental Disorders (PDD, Autism, LD, behavioral problems) - heavy Metals, Pesticides, Solvents, PCBsObesity (Metabolic Syndrome consequence DM, NASH, etc) - Built Environment, Dietary choices/lack of Physical activityEndocrine and Sexual Development Disorders (hypospadius, testicular CA) - Perchlorate, pesticides (DDT, etc.)Cancer - Solvents, pesticides?, others
13 Environmental Related Disease Is Expensive The US Department of Education spent $36 billion on special education services in the US in 1996Charges for Asthma Hospitalization in NYC for 1 – 4 year olds was $33.4 million in 2000Total annual costs are estimated to be $54.9 billion (range $ billion): $43.4 billion for lead poisoning, $2.0 billion for asthma, $0.3 billion for childhood cancer, and $9.2 billion for neurobehavioral disorders (Landrigan et al EHP 2002 Jul;110(7):721-8)
14 Environmental Exposures Are Preventable Lead can be abated. Practices that create hazards can be avoidedCO poisoning can be prevented with inexpensive detectors (New NYC Law 11/1/2004)Pesticides can be avoided – IPMLess toxic cleaning products can be chosenRadon can be detected and remediatedMold can be abated and prevented (Moisture control)Diet can be altered to reduce mercury and pesticide exposureWater can be tested for solvents and treated or replaced
15 The Theory of Children’s Unique Vulnerability Why children are not just little adults when it comes to environmental exposures
16 Unique Vulnerabilities of Children Children consume more food, drink more water, and breath faster than adultsChildren have unique behaviors, diets, and are closer to the groundChildren have immature metabolic pathwaysYoung children have unique windows of vulnerability – particularly in neurodevelopmentChildren have a very long ‘shelf life’
17 Greater ExposureChildren can have greater exposure to environmental toxins than adults.Children in the 1st six months of life drink 7 times more water.Children age 1-5 eat 3 to 4 times more food.An infants resting air intake is 2 times more than an average American adult.Pound for Pound of body weight children drink more water,eat more food, and breath more air than average American adults.
18 Unique Behaviors Hand to mouth behavior. Children play close to the ground.Unique diet.increases their ingestion of toxins in dust and soilincreases their exposure to toxins in dust, soil, carpets, and to any toxin that forms low lying layers in the air .(e.g. apples, grapes, etc)
19 Immature Metabolic Pathways Immature liver enzymes leads to increased blood levels and half-livesWell documented for therapeutic drug pharmacokineticsNot well studied for environmental toxinsGinsberg et al. Pediatric Pharmacokinetic Data: Implications for Environmental Risk Assessment for Children, Pediatrics 2004; 113:
20 Windows of Vulnerability Young children are undergoing rapid growth and critical neurologic developmentMercury - Minimata is starkest example
21 A Long ‘Shelf Life’ Children have a longer “shelf-life.” They have more future years ahead to develop illnesses with a long latency from the inciting or contributing exposure.Examples of long latencies from exposure to Cancer:Asbestos and Mesothelioma.Benzene and Leukemia.DDT and Breast Cancer.
22 Is It Really True?Recent Evidence That Supports This Theory of Children’s Unique Vulnerability to Environmental Toxins
23 Synthetic Chemicals More than 80,000 chemicals registered with EPA Greatest risk are 2,863 high-production-volume (HPV) chemicals (produced in amounts of 1 million pounds or more per year)Fewer than half have been tested for Toxicity to Human HealthLess than 10% have been tested for pediatric neurotoxicityGaps in knowledge are particularly great in regard to developmental toxicity
24 Evidence of Children’s Increased Exposure In the CDC’s 3rd National Report on Human Exposure to Environmental Chemicals (part of NHANES) many chemicals are found in greater amounts in children than adults suggesting that children really are exposed to a greater degree
25 DEHP Phthalate Plasticizer Ubiquitous use Building MaterialsClothingMedical DevicesPackagingMillions of tons produced each year
26 DEHP Potential Health Effects Developmental Toxicity in animal models (rat)Liver Toxicity in animal modelsEndocrine disruption (sexual differentiation)?Early Thelarche (breast development) associated with phthalate exposure in Puerto Rican girls. (Colon et al. EHP 2000)Decreased Testicular weight and atrophyCancer?
27 DEHP Exposure Higher in Children Third Report on Environmental Exposure to Chemicals - CDC 2005
28 ChlorpyrifosDecreased Birth Weight and Length (Pereira et al. EHP 2003)Impaired Coordination, Memory, and fine motor skills in population exposed to multiple pesticides in Mexico (Guillete et al. EHP 1998)EPA phased out of many uses in 2000
29 A Metabolite of Chorpyrifos Third Report on Environmental Exposure to Chemicals - CDC 2005
30 Addressing the Unique Vulnerabilities of Childhood Incorporating a Screening Pediatric Environmental Health History Into Routine Well Child Care and Ill Child CareAddressing the Unique Vulnerabilities of Childhood
31 Why Take an Environmental History? Clinicians can help identify and/or prevent hazardous exposuresAsking smokers about their smoking and advising them to quit has a positive quit-smoking effect on a population basisEducating parents about sun protection increases their use of sunscreen for their childrenAlthough there is little direct evidence of the effect of health provider education for other toxic environmental exposures it is reasonable to be optimistic that this positive effect will generalize.
32 When To Take An Environmental History Health supervision (“well child”) visitsUse screening environmental historyVisits for illnessUnusual presentationsPersistent or puzzling/non-specific symptomsMultiple persons with same symptoms
33 Well Child VisitsHistory, PE, monitoring growth and development, giving immunizations, performing screening testsAnticipatory guidance25-40% of US pediatricians’ time spent in well child care*To remind audience of what well child (or well adolescent) visits entail…* 2000 Nelson’s Textbook of Pediatrics
34 Integrating Questions About Environment Into The History Many areas of questioning are already part of the historyUsing Screening History Form can ensure completenessSupplemental Form provides additional informationPEH Primer gives background informationAs part of our comprehensive care, many of us already ask questions about where the child lives and spends time. Pediatric clinicians are often limited in the amount of time they can devote to a visit; the Screening History includes many basic environmental questions and can be used to make sure basic areas are covered. We recommend that the clinician administer the questionnaire but it could also be self-administered if there are time constraints. The Supplemental history can be used to elicit additional details if there are any positive responses to the Screening questionnaire.
36 Screening History Where child lives or spends time Exposure to secondhand smoke (SHS)Water source; food exposuresSun exposureExposure related to parents’ occupationsOther concerns elicited from parentImportant elements of the screening history. The first 5 areas were taken from the AAP Handbook of Pediatric Environmental Health.
37 Addressing Unique Vulnerabilities in the History Children have unique behaviors, diets, and are closer to the ground - Therefore must consider:Where child lives or spends timeSun ExposureDay Care and School are the child’s occupational settingHand to mouth behavior - Lead dust ingestionPlay spaces are potentially hazardous - e.g. BasementsChildren get ~25% of lifetime sun exposure occurs during childhood and adolescence1Schools can have their own lead or chemical exposure issuesBasements are common sites for hazardous chemical storageBasements are at highest risk for RadonChildren may play in areas like brownfields1- Godar et al. Photochem Photobiol 2003
38 Addressing Unique Vulnerabilities in the History Children consume more food, drink more water, and breath faster than adults - Therefore must consider:Water sourceFood SourcesSHSType of Heating/Cooling SystemCO detectorsInfant with formula mixed with water - greater exposure to contaminants - Uranium case, leadPesticides on Foods - CU study showing decreased body burden with organic foods
39 Addressing Unique Vulnerabilities in the History Children have immature metabolic pathways - Therefore must consider:Exposure to water contaminants like Nitrites - methemoglobinemiaSynthetic Chemicals - may have different kinetics than adults with potentially different and greater health impactsInfant with formula mixed with water - greater exposure to contaminants - Uranium case, leadPesticides on Foods - CU study showing decreased body burden with organic foods
40 Addressing Unique Vulnerabilities in the History Young children have unique windows of vulnerability and a long ‘Shelf Life’ - Therefore must consider:Potential neurodevelopmental impact of chronic low level exposures like lead and pesticidesPotential cancer risks (long latency) from UV Light exposure and Radon
41 NEEF Tools to Guide the Pediatric Environmental History PrimerScreening FormAdditional HistoryEnvironmental History for Asthma